Healthcare Provider Details

I. General information

NPI: 1154740975
Provider Name (Legal Business Name): BEHAVIORAL PAIN MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 HOBSON ROAD SUITE 244
NAPERVILLE IL
60540
US

IV. Provider business mailing address

12901 NORWICH ST
PLAINFIELD IL
60585-7908
US

V. Phone/Fax

Practice location:
  • Phone: 815-931-0047
  • Fax:
Mailing address:
  • Phone: 815-230-4707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.005140
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070009590
License Number StateIL

VIII. Authorized Official

Name: MR. AJEET S CHARATE
Title or Position: MANAGER / CLINICIAN
Credential: LCPC, BCN, CADC
Phone: 815-931-0047